SUD Referral

Returning Consumer:*
YesNo

Date*

Consumer Name: *

Date of Birth: *

SS#: *

MA#: *

Gender Assigned at Birth: *

Gender Identity: *

Sexual Orientation: *

Phone Number:*

Message OK? *
YesNo

Email Address:*

Living Situation: *

Address: *

City: *

State/Zip code: *

School/Grade (if applicable): *

Address of School: *

Preferred Method of Contact*
PhoneTextEmail

Best Time to Call: *

Are you Employed? *
YesNo

If yes*
Supportive EmploymentPTFT

Name: *

Agency (if applicable): *

Phone Number: *

Fax Number: *

Email Address: *

Relationship to Consumer: *

Name of Parent/Guardian: *

Relationship: *

Address: *

Contact Number: *

Is the consumer of Hispanic, Latino, or Spanish origin?*
YesNoUnavailable

Race: *
WhiteAsianBlack/African American American Indian/Alaskan NativeNative HawaiianOther Pacific IslanderNot Available

How well does the consumer speak English? *
WellNot so wellNot at all

Does the consumer speak another language other than English at home? *
YesNo

If Yes, what is the language? *
SpanishFrenchArabicGreekOther

Number of arrests in the past 30 days?*
None1-99

Is the consumer deaf or do they have hearing difficulty?*
YesNoUnknown

Is the consumer blind or do they have serious difficulty seeing, even when they wear glasses? *
YesNoUnknown

Currently Receiving Medication Assisted Treatment?*
YesNo

Currently Receiving Medication Assisted Treatment?*